唤醒下癫手术中突发窦性心动过缓的神经机制

Neural mechanisms of sudden bradycardia during epileptic temporal lobe surgery under awake anesthesia

目的探讨唤醒麻醉下癫手术中突发窦性心动过缓事件的可能神经机制。方法回顾性分析14例唤醒麻醉下实施颞叶切除的癫病例,手术由同一组癫外科、电生理和麻醉科医师完成。术中突发窦性心动过缓甚至心脏停搏的事件,其中发生于左侧手术12例,右侧2例。11例为术中电凝颞叶底部或海马底部蛛网膜时发生,1例为颞叶切除后误用冰盐水冲洗颅中窝术区,2例为脑压板牵拉、压迫杏仁核-岛叶时发生。事件发生后立即终止操作、消除刺激因素,严重者予阿托品等相应处理。结果采用处置措施后,待事件消失后,病人均可完成既定手术,未造成不良后果。结论唤醒状态下颞叶底部的手术操作刺激三叉神经半月节,可引发三叉神经心脏反射(trigeminocardiac reflex,TCR),这可能是突发窦性心动过缓事件的主要原因和神经机制。

Objective To explore neural mechanisms of bradycardia phenomenon during temporal lobe resection under awake anesthesia. Methods Clinical data of 14 patients suffered sudden bradycardia during epileptic temporal lobe resection under awake anesthetic condition were analyzed retrospectively. All surgical procedures were performed by the same operation group including epilepsy surgeon, electrophysiology physicians and anesthetists. There was bradycardia phenomenon or even asystole during the operation. Twelve patients occurred in the left side and 2 in the right. Bradycardia happened in 11 cases when the arachnoid at the base of the temporal lobe or hippocampus was treated with bipolar cautery, in 1 case because ice water was used for rinsing the middle cranial fossa after the anterior temporal lobe was excised, and in 2 cases whose amygadala-insula was tracted and expressed by a brain spatula. All the patients were managed successfully by cessation of the surgical manipulation or the injection of atropine. Results After cardiovascular status was re-stable, all the patients completed the further surgical procedures safely and no any adverse complications due to the event during follow up. Conclusions Surgical manipulations stimulating the trigeminal ganglion are the triggers for trigeminocardiac reflex（TCR） during awake anesthesia operations. The TCR can be reasonably regarded as the major course and neural mechanism for bradycardia during epileptic temporal lobe surgery under awake anesthesia.